VA San Diego is one of 18 hospitals around the country which will pilot becoming a "high-reliability organization."

VA San Diego Director Robert M. Smith said this new program will try to upgrade nearly every aspect of VA care.

“A lot of this is about culture change and working across the board with all of our staff," Smith said. "And working with our staff to encourage them to have that zero harm stance front and center.”

The ideas are borrowed from industries like nuclear power and aviation, where a single mistake can have disastrous consequences. It means designing systems that work, even in the face of an error.

“The reality is humans make mistakes,” Smith said. “Humans make errors, so what a high-reliability organization focus is about, is to prevent harm from occurring as a result of errors.”

As part of the announcement, the VA vowed to focus on listening more closely to patients, their families and front-line staff, moving away from a culture of blame to focus on reducing error. The Navy announced a similar plan in 2017.

The VA is announcing the new program about the same time the General Accounting Office again listed the national VA as a high-risk agency for “fraud, waste, abuse and mismanagement.” Among the issues being cited is the long wait times to see some specialists.

The VA expects all of its 170 hospitals to move toward becoming high-reliability organizations, beginning next year.